Healthcare Provider Details

I. General information

NPI: 1578387189
Provider Name (Legal Business Name): BIG MOON THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 21ST ST
HOPKINS MI
49328-9663
US

IV. Provider business mailing address

PO BOX 33
HOPKINS MI
49328-0033
US

V. Phone/Fax

Practice location:
  • Phone: 616-287-0120
  • Fax:
Mailing address:
  • Phone: 616-287-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L ZAPOLNIK
Title or Position: OWNER/BCBA
Credential: BCBA, LBA
Phone: 616-287-0120